Transcript Public Health Implications of PRWORA’s Restrictions on

Public Health Implications of PRWORA’s
Restrictions on Undocumented
Immigrants’ Access to Care
Jeff Kullgren, MPH, MSII
Michigan State University
College of Human Medicine
Overview
 PRWORA’s restrictions
 Texas situation
 Public health implications
 Policy and legal recommendations
1996 Personal Responsibility and Work
Opportunity Reconciliation Act (PRWORA)
 Enacted in 104th U.S. Congress
 “Ended welfare as we knew it”
 Set new immigration policy
 Specific language pertaining to
undocumented immigrants
PRWORA: Undocumented
Immigrants and Public Benefits
Undocumented immigrants are ineligible
for “any retirement, welfare, health,
disability…or any other similar benefit
for which payments or assistance are
provided to an individual, household,
or family eligibility unit by an agency of
a State or local government or by
appropriated funds of a State and or
local government”
Exceptions to PRWORA’s
Restrictions
1) “Assistance for health care items and
services that are necessary for treatment of
an emergency medical condition”
2)“Public health assistance for
immunizations…and for testing and
treatment of symptoms of communicable
diseases whether or not such symptoms are
caused by a communicable diseases”
3)States that enact legislation after August 22,
1996 affirmatively providing eligibility for
undocumented immigrants
4)U.S. Attorney General declaration
Trouble in Texas (2000)…
 Harris County Hospital District’s request
regarding proposed payment policy changes
 Attorney General John Cornyn’s opinion:
 PRWORA prohibits hospital district’s provision of
free or discounted non-emergency care
 No state law affirmatively providing for
undocumented immigrants’ eligibility
 Penalties for violations related to misspending of
state and federal funds
Responses to Cornyn’s Opinion
 Criminal investigation of Harris County
Hospital District and its leadership
 Pressure from local advocates for
investigations in other Texas jurisdictions
 Mixed responses from health care providers:
 Limitations on services in some areas
 Alternative legal interpretations justifying
continued service provision in others
Why Should the Public Health and Health
Care Community Care?
 Possibility for similar investigations in other
jurisdictions both in Texas and elsewhere
 Increased scrutiny of institutions particularly
in areas with large undocumented
populations
 “Chilling effect” on both providers and
undocumented patients
 Broad-ranging public health implications…
Public Health and Health Care
Implications of PRWORA’s Restrictions
 Failure to respect states’ “police
power”
 Infringement on clinicians’ ethical
obligations
 Threatened access to care for
undocumented immigrants’ children
Public Health and Health Care
Implications of PRWORA’s Restrictions
 Administrative complexities
endangering access to care for all
patients
 Prevention of cost-effective use of
public resources
 Hindrance of infectious disease
diagnosis and tracking
Law and Public Health Policy
 Law presumably intending to revamp
provision of public assistance has
reshaped public health practice
 Anti-immigrant sentiments of mid1990’s captured and controlled debate
 Policy driven by rhetoric not evidence
 Impractical constraints and unintended
consequences
Macro-Level Strategies for
Resolving this Conflict
 State legislation affirmatively providing
for undocumented immigrants’
eligibility
 U.S. Attorney General exemptions
 Federal legislation amending PRWORA
 Formation of untraditional alliances
Micro-Level Strategies in the
Absence of Broad Reform
 Local agreements with district
attorneys and law enforcement officials
 Continued provision of services until
judicial system addresses this issue
 Public health leaders’ provision of
expert knowledge and amicus curiae
briefs if needed
Important Public Health Policy
Research Questions
 How have public health and health care
institutions been affected?
 Can the infectious disease and
epidemiologic implications be
quantified?
 Case studies of public health
consequences?
 What are the “pull factors” driving
illegal immigration?
Conclusion
 PRWORA went much further than
reforming welfare
 Important public health implications
related to undocumented immigrant
restrictions
 Utility of Harris County’s experience as
a case study
 Urgent need for macro and micro-level
efforts to resolve this conflict